The ileocaeco-urethrostomy with multiple transverse taeniamyotomies for bladder replacement: an alternative to detubularized neobladders. Morphological, functional and metabolic results after 9 years' experience

OBJECTIVE

To evaluate the results from the long-term follow-up of ileocaeco-urethrostomy with multiple transverse taeniamyotomies for bladder replacement.

PATIENTS AND METHODS

Since 1987, 60 male patients have undergone bladder replacement using a technique of ileocaeco-urethrostomy with multiple transverse taeniamyotomies. Avoiding detubularization, sectioning the caecal taeniae improved reservoir morphology and reduced internal pressures and wall tension, limiting the potential complications of the operation.

RESULTS

All patients achieved diurnal continence with socially acceptable intervals between micturitions. Immediately after the operation, the nocturnal continence rate was good (79% of patients with a follow up < 3 years), reaching 86% after > 3 years. After 5 years, the reservoir capacity remained within the physiological range (mean volume 469 mL) with a mean maximum internal pressure of 47.6 cmH2O, while the mean post-micturition residual volume was 28 mL; no patient needs to use self-catheterization. Given the short intestinal length used, no metabolic clinical problems have occurred.

CONCLUSIONS

The concept of using the caecum arose from physiological and anatomical assumptions, i.e. receptive relaxation, the presence of taeniae and ileocaecal sphincter. Taeniamyotomies can achieve the same goals as detubularization, i.e. a reduction of wall tension and internal pressure and a near-spherical shape, but, in contrast, by leaving the circular muscle intact, they allow a good basal tone to be maintained thus obtaining optimal emptying and avoiding deterioration of the reservoir.

[ESWL for urolithiasis in a patient with transileal ureterocutaneostomy]

We present a case of urinary stone originated in the upper urinary tract and impacted within the ureteroileal anastomosis, in a patient with ileal conduit urinary diversion. Extracorporeal shock wave lithotripsy (ESWL) showed itself resolutive. Patients with urinary diversion have multiple risk factor for calculi formation (acidosis with concomitant hypercalciuria, upper urinary tract infections with urease producing bacteria, urostasis due to ureterointestinal anastomosis or ureteral narrowing), as well as predisposing conditions for stones to impact along the ureter or within the ureterointestinal anastomosis. Follow-up of these patients has to be very careful in order to avoid obliterative pyeloureteritis, the major complication of stone disease in patients with urinary conduit diversion.

Bladder replacement by detubularized ileal loop: 10 years of experience using a personal technique

OBJECTIVE

To evaluate the results obtained with a technique of bladder replacement using a detubularized ileal tract, developed by the authors.

PATIENTS AND METHODS

Since 1983, 34 patients have undergone an orthotopic bladder replacement using 35-40 cm of ileum, detubularized and shaped into an 'S' to create a neobladder with a capacity of 100-120 mL. The ureters were anastomosed directly to a 10 cm long intact afferent loop which serves as an anti-reflux mechanism, while a 2 cm long efferent, spatulated loop was used for urethral anastomosis. The mean (SD) follow-up was 32 (33) months.

RESULTS

All the patients were continent during the day, with socially convenient intervals between voids; 3 years after the operation, 10 of 12 patients were continent during the night, with intervals of 2-4 h between voids. The mean post-void residual urine volume was 41 mL and no patient required self-catheterization. There were no derangements of the metabolic status of patients.

CONCLUSION

This technique was applied knowing that a detubularized intestinal loop has the remarkable ability to increase in capacity over time. Therefore, to maintain the reservoir in good condition over a long period it is important to construct it with an intra-operative capacity of < 120 mL, thus reducing the length of intestine required. This may explain the satisfactory metabolic status of these patients. Moreover, the triplication of the mesentery helps to maintain the sphericity of the neobladder and provides support for the neobladder in the lower pelvis, where it retains the same position as a normal bladder.

[Urodynamic picture in high spinal cord ischemia, induced by addictive use of cocaine. Report of a case]

The authors present a case of spinal cord ischemia at level C2 related to cocaine use. The neurologic pattern was an anterior cord hemisection syndrome. Urodynamic assessment was performed at 6 and 14 months from the neurovascular event. The ice-water test (IWT) showed an uninhibited bladder cooling reflex, despite an areflexic detrusor (at routine filling cystometry). Occult bladder hyperreflexia became overt during the following month and was registered by the second urodynamic assessment. Anatomical bases of spinal cord blood supply are discussed. The authors emphasize the role of the IWT in predicting the development of overt bladder hyperreflexia and thus, spinal shock phase resolution.

Results of 4 years of experience with bladder replacement using an ileocecal segment with multiple transverse teniamyotomies

Since 1987, 30 patients with bladder cancer underwent cystoprostatectomy with bladder replacement via ileocecourethrostomy. Multiple transverse teniamyotomies were made in the cecum to assure a large capacity reservoir with low pressures. The particular anatomy and physiology of the cecum, short length of the intestinal segment needed and teniamyotomies are the 3 factors that have allowed for good functional and metabolic results. All patients achieved daytime continence. After 3 years of followup 67% of the patients were continent at night if they voided every 3 or 4 hours and 22% if they voided every 2 or 3 hours, while 11% experienced enuresis. Urodynamic data after 1 year showed a mean capacity of 396 ml. for the new bladder, a mean full filling pressure of 28 cm. water and a mean maximum pressure of 55 cm. water. Post-micturition residual urine volume was consistently less than 55 ml. These results indicate that the ileocecal segment can be enlarged with myotomies through the tenia to produce an adequate capacity and a low pressure bladder replacement without the need for formal detubularization.

Bladder replacement by ileocaeco-urethrostomy or ileo-urethrostomy with a reservoir after cystoprostato-vesiculectomy for bladder cancer. A functional evaluation

The purpose of this study was to evaluate the function of the intestinal segments used to replace the bladder after cystoprostato-vesiculectomy. The series included 30 patients, 10 of whom underwent clinical, radiological, urodynamic and electromanometric investigations. Seven patients had an ileocaeco-urethrostomy (ICUS) and 3 had an ileo-urethrostomy with a reservoir (IR). The results were good in all patients and there was no sign of tumour recurrence. All were completely continent during the day but during the night only those who observed the 2-h intervals between voiding were continent. The radiological findings for 1 patient showed grade I asymptomatic vesicoureteric reflux. In all cases, periodic pressure waves were observed during electrocystomanometric tests at basal levels, with the IR patients showing waves higher in frequency and lower in amplitude. Prostigmin induced a significant variation in motor activity in IR patients only. The urodynamic tracings showed an almost physiological flow in both groups. Cystomanometry revealed good compliance in both types of new bladders. The height and width of contraction waves during filling was greater in ICUS than in IR patients. Good perineal sphincteric activity was demonstrated by electromyography. Low passive resistance was indicated by the urethral pressure profile. Preliminary analysis of data indicated good functional micturition and renal function in both ICUS and IR patients. Slight differences were found between the two intestinal segments used for bladder replacement.

Peristalsis in distal colon of the rabbit: an analysis of mechanical events

The mechanical behavior of isolated segments of rabbit distal colon was studied by experimental and theoretical techniques. The isometric isovolumic preparation was adopted to obtain records of endoluminal pressure, force, and wall morphology during 59 spontaneous and 53 electrostimulated peristaltic contractions. On strips of longitudinal and circular muscle, excised from the same segments, the tension-velocity and tension-length relationships were also measured. To describe mechanical events occurring during propulsion, a mathematical model was developed that incorporates the measured characteristics of the muscle. In response to given waveforms for the activation of the two muscular coats, the solution of model equations provides the time courses of pressure, force, and wall morphology. A number of parameters measured in the experimental contractions (e.g., pressure and force peaks, time lag between the stimulus and the peaks, velocity of progression of the peristaltic wave) were compared with model outputs, and a similar pattern of response was found. Therefore the model made it possible to relate segment and strip experimental data and to investigate the temporal and quantitative relationship between the contraction of longitudinal and circular layer.